Quality improvement project to enhance adherence to RCEM standards for patients with paracetamol overdose

Delayed or inconsistent administration of N-acetylcysteine (NAC) for paracetamol overdose in the emergency department (ED) poses a risk to patient safety, with current Royal College of Emergency Medicine (RCEM) standards often not being met. The traditional 21-hour NAC regimen is associated with adverse drug reactions, medication errors and prolonged admissions. The Scottish and Newcastle Acetylcysteine Protocol (SNAP) was introduced as a simpler alternative with comparable efficacy. This quality improvement project (QIP) aimed to improve compliance with RCEM standards by implementing targeted interventions while also reducing the length of inpatient stay and maintaining patient safety.

This QIP was conducted at Royal Derby Hospital using a multidisciplinary, systematic approach based on Plan-Do-Study-Act cycles. Baseline data were collected from 100 randomly selected patients (November 2021-May 2022) and compared with outcomes during a 52-week intervention period (September 2023-August 2024). Interventions included educational sessions, quick reference materials and enhanced prescribing tools. Data were analysed for compliance with RCEM standards, adverse events (liver function derangement and anaphylactoid reactions) and system-level measures, such as length of inpatient stay and timing of paracetamol plasma levels.

A total of 214 patients were included. Compliance with RCEM standard 1 improved from 36% to 43%. No change was noted for standards 2 and 3. Median inpatient stay decreased from 35 hours to 30.5 hours. No significant differences were found in adverse events. Special cause variation was identified in paracetamol plasma level timing, attributed to early sampling in some cases.

This QIP addressed problems of delayed or inconsistent NAC administration in the ED by improving compliance with RCEM standard 1 and reducing inpatient stay while maintaining patient safety. Although standards 2 and 3 did not improve, the interventions proved cost-effective, feasible and scalable. Future work should focus on sustaining improvements and exploring patient-centred outcomes across diverse healthcare settings.